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The nurse is preparing to speak to the facility’s social worker about the client’s condition. Select the 5 findings the nurse should plan to include in the report.

Client’s report of lack of access to bank accounts

Client’s avoidance of eye contact

Client’s report of weight loss

Numerous bruises in various stages of healing

Client’s report of lack of food in the house

Client’s strong body odor

Right arm fracture

Answer and Explanation

Correct Answer : A,D,E,F,G

The nurse should plan to include the following five findings in the report to the social worker, as they raise significant concern for elder maltreatment:
Findings to Include
•   A. Client’s report of lack of access to bank accounts → Suggests financial exploitation, especially since the client gives income to the adult child but cannot access funds.
•   D. Numerous bruises in various stages of healing → Strong indicator of physical maltreatment, possibly repeated trauma over time.
•   E. Client’s report of lack of food in the house → Points to neglect, particularly in meeting basic nutritional needs.
•   F. Client’s strong body odor → Suggests neglect in hygiene and personal care.
•   G. Right arm fracture → A confirmed injury that, in context with other findings, may not align with a simple accidental fall.
Findings Not Prioritized for Reporting
•   B. Client’s avoidance of eye contact → May reflect fear or discomfort, but is not specific enough to confirm maltreatment.
•   C. Client’s report of weight loss → While potentially concerning, it wasn’t documented in the case and lacks supporting data like previous weight or timeframe.

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Correct Answer is B

Explanation

Choice A rationale

A healthcare surrogate, or proxy, is a person designated by the patient themselves through a legal document called a durable power of attorney for healthcare. The provider's role is to provide medical care, not to make legal decisions for the patient. The patient retains the autonomy to choose who will make decisions for them when they are unable to do so. This is a fundamental principle of patient self-determination and legal rights.

Choice B rationale

A patient's competency can fluctuate. In situations of temporary incapacity, such as during a surgical procedure with anesthesia or a period of severe illness, a health care surrogate may make decisions. However, once the patient regains competency and is able to make informed decisions for themselves, they automatically resume control of their health care. This is a core tenet of patient autonomy and the purpose of advance directives.

Choice C rationale

A healthcare surrogate does not have to be a family member. The person designated by the patient can be a friend, a partner, or any trusted individual. The only requirement is that the surrogate is an adult who is willing and able to make healthcare decisions on the patient's behalf. It is a legal designation, not a familial one, that is based on the patient's trust and personal wishes.

Choice D rationale

A provider is legally and ethically obligated to follow a patient's wishes as outlined in their advance directives, as long as those wishes are within the bounds of standard medical practice and are not medically futile. To go against a patient's documented wishes would be a violation of patient autonomy and a breach of the legal protections afforded by advance directives.

A. A 12-year-old child who has cystic fibrosis and reports difficulty clearing secretions. B. A 3-year-old child who has an atrial septal defect and a heart rate of 120/min. C. A 2-year-old child who has diarrhea and reports abdominal pain. D. A 5-year-old child who has type 1 diabetes mellitus and a blood sugar of 150 mg/dL.

Correct Answer is A

Explanation

Choice A rationale

This 12-year-old child with cystic fibrosis and difficulty clearing secretions is the priority. Cystic fibrosis causes thick mucus to accumulate in the lungs, leading to airway obstruction. Inability to clear these secretions indicates a potential acute respiratory crisis, which can rapidly progress to respiratory failure. This is a life-threatening airway and breathing emergency requiring immediate assessment and intervention to prevent respiratory compromise.

Choice B rationale

A 3-year-old with an atrial septal defect and a heart rate of 120/min is a non-acute finding. A heart rate of 120/min is within the normal range for a toddler (90-140/min) and is a common physiological response in a child with a heart defect to maintain cardiac output. This child is stable and does not present with an immediate life-threatening condition.

Choice C rationale

A 2-year-old with diarrhea and abdominal pain is a non-acute finding. While these symptoms require attention, they are common in toddlers and do not typically represent an immediate life-threatening emergency unless accompanied by signs of severe dehydration or septic shock. Other children with respiratory issues take priority due to the higher potential for rapid decompensation.

Choice D rationale

A 5-year-old with type 1 diabetes mellitus and a blood sugar of 150 mg/dL is stable. A blood sugar of 150 mg/dL is within a safe, controlled range for a child with type 1 diabetes, which is typically 80-180 mg/dL. This child does not require immediate intervention as their blood glucose is not indicative of hypo- or hyperglycemia crises. .

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The nurse is preparing to speak to the facility’s social worker about the client’s condition. Select the 5 findings the nurse should plan to include in the report.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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